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Summary
Why is wound documentation important?

What is included in wound documentation?

What are the benefits of adequate and clear documentation?

Let’s summarize our discussion today. We hope that we have provided some insight to the questions on this slide.

First, why is it important to document wounds, including care and treatment? Documentation provides the communication necessary to provide optimal care planning, monitoring of progress, and successful insurance coverage for care and treatment.

 

What is included in wound documentation? In a nutshell, it should include documentation of wound characteristics, documentation to justify treatment and supplies using care to match these to the wound characteristics, prognosis for wound healing, documentation of ongoing monitoring for both progress and problems--or barriers to wound healing, and orders that match up with the objective documentation of the wound and all conditions that may affect proper wound healing.

 

Finally, what are the benefits of proper documentation? We hope that it will be clear that proper documentation can improve patient care and treatment, the effectiveness of your interventions – especially those that cross from in-patient to out-patient care - and help to assure accurate reimbursement to reduce the patient’s financial burden for additional needed care and supplies. 

 

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